Desensitization in the Era of Kidney Paired Donation

Desensitization in the Era of Kidney Paired Donation

Mark D. Stegall, M.D.Mark D. Stegall, M.D.

• Institution : Mayo Clinic, Rochester.

• Research contracts with Alexion and Millenium

• My presentation includes discussion of off-label and investigational.

• Yes—Eculizumab, Alexion Pharmaceuticals;

• Institution : Mayo Clinic, Rochester.

• Research contracts with Alexion and Millenium

• My presentation includes discussion of off-label and investigational.

• Yes—Eculizumab, Alexion Pharmaceuticals;

Disclosure. Disclosure.

The Limits of Paired Donation: The Limits of Paired Donation: Who Doesn’t Get Transplanted?Who Doesn’t Get Transplanted?The Limits of Paired Donation: The Limits of Paired Donation: Who Doesn’t Get Transplanted?Who Doesn’t Get Transplanted?

Deceased Donor ListDeceased Donor List

9000 cPRA>95%

Transplant Rates by cPRATransplant Rates by cPRA

4400/6 mos

Actual Death-Censored5 Year Graft Survival

Actual Death-Censored5 Year Graft Survival

70.7% vs 88.0%, p= 0.0006

Paired DonationPaired Donation

63% cPRA>95%

National Kidney Registry

Mayo Foundation 3-Site KPD Program

Mayo Foundation 3-Site KPD Program

• Cooperative: virtually one cost center and one protocol

• Screen multiple donors (HLA type) and do full workup when a chain emerges

• Cooperative: virtually one cost center and one protocol

• Screen multiple donors (HLA type) and do full workup when a chain emerges

Two ErasTwo Eras

• Phase I: Avoid desensitization• Accept +XM up to channel shift of

200 (3000 MFI or so)• 8/2009-12/2012 (90 KPDs)

• Phase II: Allow desensitization• 3 months is KPD• If no chain, then allow +XMKTx with

desentization• 1/2013--present

• Phase I: Avoid desensitization• Accept +XM up to channel shift of

200 (3000 MFI or so)• 8/2009-12/2012 (90 KPDs)

• Phase II: Allow desensitization• 3 months is KPD• If no chain, then allow +XMKTx with

desentization• 1/2013--present

Figure 1Figure 1T

ime

(D

ays

)

cPRA

cPRA by MFI

Phase IIKPD + Desensitization

Phase IIKPD + Desensitization

Patient cPRA (%)Waiting time

(days)Transplant

groupDesensitization

(Y/N)B-Flow XM

1 99 495Original

Intended DonorN 123

2 99 1018 Paired Donor N 1913 99 1019 Paired Donor Y 305

4 99 1147Deceased

DonorN 0

5 99 187Original

Intended DonorY 160

6 99 723Deceased

DonorY 206

7 99 1263 Paired Donor Y 215

8 91 428Original

Intended DonorY 248

9 95 20 Paired Donor N 137

10 99 236Original

Intended DonorY 316

Recipients with cPRA >90 who received a Transplant in Phase 2

Phase IIKPD + Desensitization

Phase IIKPD + Desensitization

10 cPRA >95% transplanted

Phase IIKPD + Desensitization

Phase IIKPD + Desensitization

10 cPRA >95% transplanted4 KPD

2 no desensitization2 desensitization (lower +XM)

Phase IIKPD + Desensitization

Phase IIKPD + Desensitization

10 cPRA >95% transplanted4 KPD

2 no desensitization2 desensitization (lower +XM)

4 original donor

Phase IIKPD + Desensitization

Phase IIKPD + Desensitization

10 cPRA >95% transplanted4 KPD

2 no desensitization2 desensitization (lower +XM)

4 original donor2 deceased donors

ConclusionsConclusions

• Sensitized patients have more transplant options than before

• Sensitized patients have more transplant options than before

ConclusionsConclusions

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

ConclusionsConclusions

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

ConclusionsConclusions

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

• +Crossmatch Kidney Transplant may be the only viable option

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

• +Crossmatch Kidney Transplant may be the only viable option

ConclusionsConclusions

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

• +Crossmatch Kidney Transplant may be the only viable option

• New therapies are needed to control antibody and its effects on the kidney transplant

• Sensitized patients have more transplant options than before

• Donor without antibody is ideal—paired donation/deceased donation

• Donor with lowest level of antibody is the next best option

• +Crossmatch Kidney Transplant may be the only viable option

• New therapies are needed to control antibody and its effects on the kidney transplant